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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Tuesday, July 24, 2007
    The Lipid Wars

    Cholesterol: The bane of every internist. If I had a buck for every patient I've argued with about starting a statin to treat their elevated cholesterol, I could probably retire right now. There are a couple reasons for this. First, the guidelines for "normal" LDL levels are getting tighter all the time. This means that my patients who formerly needed to lower their cholesterol 20 or 30 points may now need to lower it by 50 to 60 points. Their lipids haven't changed; the rules have. Second, people don't really like taking statins, even the ones whose cholesterol is close to 300. These medications have the potential to injure the liver, although we prevent that by following patients' blood tests; if the liver enzymes go up we stop the drug. There is no permanent liver injury. A much more frequent side effect of statins is muscle aches. Most of the time when I've had to stop statin treatment it has been for this reason.

    The other issue besides side effects and the cost and annoyance of taking a drug is the overly optimistic view patients have of the effectiveness of diet and lifestyle changes. ("I'll change my diet!" If I had a buck for every time I heard that, I'd be as rich as Bill Gates.) Don't get me wrong: cutting fat out of the diet does lower cholesterol. But to make a significant change such as fifty points or more requires a very strict, usually vegetarian, lowfat diet.

    I have one such diet sheet which I hand out to patients as an example of what it's going to take to lower their cholesterol without drugs. I love to watch their faces fall in disbelief as they read it. Next predictable question: "How long do I have to do this?" I answer: "The rest of your life." High cholesterol is simply not a curable problem. Controllable, yes, but not curable. I have to tell people over and over again that no matter what we do for their cholesterol - medication, lifestyle changes, or both - the problem will never really go away. Most people go off the wagon at some point, which is understandable. When they do the cholesterol profile worsens almost immediately, with the HDL going down and the LDL going up.

    The effects of high cholesterol take years to decades to appear. It's difficult to get someone to buy into taking medication that costs money and can have side effects when they won't see the benefits for many years to come. And it's a negative benefit at that, as in they won't get a heart attack. It isn't about achieving something, it's about preventing something. Psychologically, no wonder this is a struggle.

    I've had patients suggest red yeast rice as an alternative. Sad news, folks: the product as it is currently available does not lower cholesterol. It did in the past because the original formulation contained lovastatin (brand name Mevacor), the same as the prescription drug that lowers cholesterol, just in a lower concentration. The FDA banned it from being sold as a dietary supplement, since it contained an active ingredient that was classified as a drug; the manufacturers pulled it, reformulated it and started selling it again. Unfortunately once the lovastatin was removed, the rice product was useless as a treatment.

    All of this is a leadup to a conversation I had yesterday with a new patient. I had just found out that he has high cholesterol and thought: well, he's young. We can try diet first and I'll check his labs again in three months. I called him, went through the numbers with him, explained what they meant and touted the benefits of a high-fiber, low-fat diet...

    Me: "...and we'll check your fasting cholesterol again in three months."

    Patient: "Do you think I need medication for this?"

    Me: "Well, uh, sure we could do that, and you may need medication. But I think we could work on diet and exercise first."

    Patient: "Are you sure I don't need medication?"

    Me: *head explodes*

    Apparently the negative psychology ploy really does work. Who knew?




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